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Re assign ein field

[Music] hello and welcome to our video about completing the CMS 855 our application for physicians or non-physician practitioners to reassign Medicare benefits to a sole proprietor organization or group before we begin here are some tips to identify the difference between CMS Part B Medicare enrollment applications CMS 855 I for individuals physicians or non-physician practitioners CMS 855 B for business clinics or group practices and Part B suppliers CMS 855 R for reassignment reassignments of Medicare benefits CMS 855 o for ordering certifying and prescribing eligible ordering certifying and prescribing physicians and other eligible professionals and CMS 2:01 34 for Medicare diabetes prevention program in DPP suppliers during this video we will go over completing the CMS 855 our application for a physician or non physician practitioner to reassign Medicare benefits to an eligible organization or group which may be an individual practitioner a clinic or group practice or other health care organizations a physician's assistant PA will not complete this application the CMS 855 I will need to be completed to show the PJs employment arrangement with the organization or group in addition to completing a CMS 855 our application if the physician or non physician practitioner is new to the Medicare administrative contractor back for the state the services are rendered they will also need to complete a CMS 855 I application each required section of the CMS 855 our application will be addressed and we will go over some helpful tips in certain sections to prevent delay in your application process let's begin completing the application in order to locate CMS form 855 are you will first need to navigate to ngsmedicare.com once you have selected your line of business and state and accepted the 8's station click on the enrollment mega tab then select enrollment forms and finally you will click on the CMS 855 our form who should complete this application all physicians and non-physicians practitioners other than physician assistants that will be reassigning medicare benefits a separate CMS 855 are must be submitted for each organization or groups tax ID or individual social security number or employee ID number where reassignment of benefits is being established continue reading the instructions on page 1 for additional information including a link to the CMS provider enrollment dedicated webpage at the bottom of the page is instructions for completing the application there is additional information at the top of the next page including a link to build the provider enrollment chain and ownership system Pecos in the CMS paper applications Pecos School electronic submission of the 855 our application instead of filling out the paper application form definitions are clarified as to when to use the add change and remove fields and at the bottom of the page are instructions on how to locate the fee for service contractors mailing address this paper application can be downloaded and completed online once complete print the application and have the individual physician or non physician practitioner and the authorized or delegated official of the group sign in date section six certification statement and signatures and mailed the application to the appropriate fee for service contractor section one basic information starting at the top of page three under reason for submitting this application select you are enrolling or currently enrolled in Medicare and will be reassigning your benefits indicate the effective date and then complete all sections as instructed section two organization or group receiving the reassigned benefits all fields must be complete indicate either the organization or groups information in Section A or the individual practitioners information in Section B as applicable the legal business name and tax identification number must coincide with the information on the Internal Revenue Service record this includes any suffixes also supply the organization or groups type to national provider identification NPI and Medicare identification number if you are reassigning your benefits to an individual the individuals legal name and social security number must coincide with the information on the social security record also supplied the individual type one at national provider identification NPI and Medicare identification number if applicable indicate the individual's employee identification number E I n the Medicare identification number is the provider transaction access number piece and that was issued by the Mac when the enrollment was approved if the enrollment application is still pending or is being submitted with the CMS 855 are the P 10 is not required if you have multiple pete's hands under one tax ID copy and complete the section for each connecting Pete and section three individual practitioner who is reassigning benefits all fields must be complete provide the information about the individual physician or non physician practitioner who will be reassigning their benefits the name date of birth and social security number must coincide with information on the social security record also supply the individuals type 1 and national provider identification NPI and because this is a new request right pending in the Medicare identification number field section for primary practice location this section is optional identify the primary practice location where the individual will render services most of the time for the entity the location must be currently enrolled or is enrolling with Medicare include the P tan or NPI of the location if different than the information reported in section 2 of this application at the bottom of the page also optional identify a secondary practice location section 5 contact person information this section is also optional indicate who you want us to contact if you have questions about this application you can have multiple contacts copy and complete this section for each individual and complete all fields if a contact person is not listed we will only be able to talk to the individual physician or non physician practitioner regarding this application change add and remove with effective date can be used to update current contact information section 6 certification statements and signatures section 6 a individual practitioner certification statement and signature an individual practitioner is the only person who can sign section 6 a the authority to sign the application on their behalf may not be delegated to any other person the applicant must read this section and by signing and dating the individual is authorizing the organization or group or individual practitioner identified in section 2 to receive Medicare payments on their behalf section 6 be delegated or authorized official of organization or group a certification statement into by signing and dating and authorized or delegated official certifies that information is true accurate incomplete on this application the signatures in section 6 a and 6 V authorized the reassignment of benefits between the individual practitioners shown in section 3 and the organization or group or individual practitioners shown in section 2 these signatures also serve as an a test station and acknowledgement to the compliance with all laws and regulations pertaining to the reassignment of Medicare benefits all signatures must be original and in ink stamped signatures will not be accepted the last page of the application indicates the Medicare supplier and Ruhlman Application Privacy Act statement read this section before submitting the application now that you've completed the CMS 855 R for the physician or non physician practitioner please view the video for completing the CMS 855 B to enroll a clinic or group practice if the organization or group has not yet enrolled with Medicare if we assigning to an individual practitioner identified in section 2 that has not yet enrolled with Medicare that individual will need to complete the CMS 855 ID if the applicant identified in section 3 is new to the Medicare program or from another state or jurisdiction view the video for completing the CMS 855 I to enroll a physician or non physician practitioner reassigning all benefits stay tuned to our YouTube channel for more educational opportunities designed for you